Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. For one resident with a history of shortness of breath, acute respiratory failure, dysphagia, cerebral infarction, and dementia, surveyors observed that suction equipment, including a canister, tubing, and Yankauer suction tip, was available at the bedside but was not labeled or dated as required by facility policy. This lack of labeling was confirmed over two consecutive days, and staff interviews verified that the equipment should have been labeled with the date it was opened and changed every seven days. For another resident with diagnoses including chronic obstructive pulmonary disease, heart failure, dementia, and schizoaffective disorder, the oxygen concentrator was observed to be set at 3.5 liters per minute, despite a physician's order for 2 liters per minute via nasal cannula. Multiple observations over two days confirmed the oxygen was consistently set above the ordered rate. Staff later verified the discrepancy between the physician's order and the actual oxygen flow rate being administered.